Garry Rayno's State House Dome: The new face of health care

The new face of health care is beginning to emerge from the corners of the Affordable Care Act, and New Hampshire had its glimpse the past two weeks.

First, Anthem Blue Cross Blue Shield revealed aspects of its Pathway program, developed for the health insurance marketplace, or exchange, and then Harvard-Pilgrim, Dartmouth-Hitchcock Medical Center and Elliot Health Systems rolled out their ElevateHealth plan.

The Pathway program is the backbone of the health plans Anthem will offer beginning Oct. 1 to those buying insurance through the state's electronic marketplace. Anthem is the only health insurer on the state's exchange, although Delta Dental is an approved dental insurer.

ElevateHealth will be available only to employers initially, but is expected to be available on the marketplace in 2015 for individuals. The plan is touted as promoting high-quality health care at a roughly 10 percent lower premium cost.

Anthem says the Pathway program will lower premiums by 25 percent from what individuals could have expected to pay for the additional benefits mandated for exchange policies and to absorb the state's high-risk pool of 3,000 individuals who have been denied private health insurance.

The Harvard-Dartmouth-Elliot project is what is called an Accountable Care Organization (ACO) - integrated health systems that coordinate patient care and chronic-disease management through a "patient-centered medical home" or primary care physician. Something like managed care on steroids.

The idea is to provide better care for less money, and the ACA provides significant up-front money to establish ACOs.

The Pathway program is not technically an ACO, but the concept is pretty much the same because Anthem decided which hospitals and affiliated physician practices and services would be in the network. Not included are some small rural hospitals, the state's two for-profit hospitals in Portsmouth and Derry, Concord Hospital, Southern NH Medical Center in Nashua and Frisbie Memorial Hospital in Rochester.

The Pathway network includes 16 of the state's 26 hospitals, as well as Lahey Clinics.

The Harvard-Dartmouth-Elliot group also includes Southern NH Medical Center, Cheshire Medical Center and New London Hospital.

Along with two new networks, the three managed care companies the state hired to run its managed care Medicaid program, which begins Dec. 1, have also established selective networks of hospitals and their affiliated practices.

All 26 hospitals have to be included in a least one of the three managed care networks.

Individuals buying health insurance through the marketplace will be on Anthem's narrower network, including the 3,000 people in the high-risk pool, as will current Anthem individual policyholders when their policies expire. Also included will be any employer purchasing insurance on the exchange, although small-business mandates will not go into effect until January 2015, so few if any are expected to use the exchanges.

The new, smaller network would not affect Anthem customers who receive health insurance from their employers or if they are on Medicaid or Medicare.

Harvard-Pilgrim business customers will be offered a choice between ElevateHealth and their current policy's broader network, with a 10 percent higher premium.

Combine the two business models and it is not difficult to see where coverage is headed: Fewer provider choices and cheaper premiums in the short-term.

Many people will have to change their primary care physician and hospital and travel farther for health care services. In return, the individual insurance market will have expanded benefits and a greater number of people with health insurance.

When Anthem announced its Pathway program two weeks ago, company officials cited a national survey showing that when offered a choice, consumers believe price is overwhelmingly more important than easy access to health services. We'll soon see whether that is true in the Granite State.

Much has been made in New Hampshire about the expansion of Medicaid eligibility that would add about 48,000 people to the program in return for $2.4 billion in federal money, but shifts in the private-payer system are going to be even more pronounced in the coming years. The Medicaid program is not going to change much at all, but private insurance is.

The new normal is going to be very different for many New Hampshire residents, just as it was when managed care was first introduced.

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Medicaid Expansion: The moment everyone has been waiting for is almost here.

The Commission to Study the Expansion of Medicaid Eligibility this week begins discussions among its members on the recommendations for lawmakers.

To date, the commission has heard from state health and insurance officials, national experts, local experts, proponents and opponents, providers and social service advocates.

Now the commission, which has a 5-4 Democratic advantage in appointments, needs to begin to craft a recommendation that will garner the two Republican votes in the Senate needed to approve expansion.

One likely component is the state's Health Insurance Premium Payment program, which pays to continue private health insurance for low-income adults through Medicaid.

The program is small at the moment, but could grow rapidly if lawmakers decide to move forward with an expanded program to provide continued coverage to people who fall between 100 percent and 138 percent of the federal poverty level.

Another likely scenario is to use Medicaid funds to pay for qualifying adults to purchase insurance on the electronic marketplace, which means through Anthem, and then pay for the additional services included under Medicaid, such as transportation.

An alternative proposal to Medicaid expansion from Avik Roy, senior fellow at the Manhatten Institute and Forbes Magazine blogger, became a hot-button issue soon after he laid out the rough outline of a plan Tuesday before the commission.

Republicans called it an opportunity to reach a New Hampshire solution, while Democrats said it was more expensive and covered fewer people with reduced benefits.

Beginning Tuesday, the expansion committee members try to determine what goals they have for expansion, if that is what lawmakers ultimately decide to do.

The committee has a month to present its recommendations, at which time Gov. Maggie Hassan is likely to call a special session for lawmakers to decide whether the recommendation is acceptable.

Hassan and the Democrat-controlled House favors expansion of the current program to cover adults earning up to 138 percent of the federal poverty limit, while the Republican-controlled Senate refused to include expansion in the state's two-year operating budget and instead opted to establish the commission, which is where it stands.

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New Bills: Last week, House members were able to begin filing requests to draft bills with Legislative Services.

The House filing period lasts through Sept. 29, although committee members studying bills have until December to file their requests, known as LSRs.

Senators can file LSRs between Sept. 30 and Oct. 25.

Usually, the second year of a Legislature's term-year term is more partisan, as both parties position themselves in regard to hot-button issues going into an election year.

The drafting requests range from the essential to the sublime, the earnest to the ridiculous.

We will know soon enough whether this year follows the usual route.

New Senate Communications Director: Tom Cronin is the Senate's new communications director, replacing Carole Alfano, who resigned to take a similar position at the New Hampshire Supreme Court.

Cronin has been the Senate's majority (Republican) caucus director since 2010.

He served on the Washington, D.C., staff of former U.S. Sen. John E. Sununu and was press secretary for Ovide Lamontagne's gubernatorial bid in 2012.